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”‡“—‹”‡†ƒ††‹–‹‘ƒŽ‡ˆˆ‘”––‘
‘’Ž‡–‡†—‡–‘–Š‡—ƒ–‹
‹’ƒ–‡†—„‡”‘ˆƒŽ–”ƒ•”‡˜‹‡™
‹–‡”ƒ–‹‘•ƒ†–Š‡Žƒ”‰‡—„‡”‘ˆ”‡˜‹‡™‡”•Ǥ


–™ƒ•‘”‹‰‹ƒŽŽ›ƒ••—‡†–Šƒ–‘‡•‡–‘ˆ”‡˜‹‡™
‘‡–•™‘—Ž†„‡’”‘˜‹†‡†„›–Š‡‹–›
ƒ†‘‡•‡–™‘—Ž†„‡’”‘˜‹†‡†„›ƒŽ–”ƒ•ǤƒŽ–”ƒ•”‡“—‡•–‡†‡‹‰Š–”‡˜‹•‹‘•–‘–Š‡ ƒ†–™‡Ž˜‡”‡˜‹•‹‘•–‘–Š‡’”‹‘”–‘ˆ‹ƒŽ‹œƒ–‹‘Ǥ ϱ͘dƌĂĨĨŝĐŶĂůLJƐŝƐ
—‡–‘–Š‡ƒ˜ƒ‹Žƒ„‹Ž‹–›‘ˆ—’†ƒ–‡†–”ƒˆˆ‹

‘—–ƒ†
‘ŽŽ‹•‹‘†ƒ–ƒ•‡–•ǡƒŽ–”ƒ•”‡“—‡•–‡†ƒ
”‡˜‹•‡†–”ƒˆˆ‹
ƒƒŽ›•‹•ǤŠ‡—’†ƒ–‡††ƒ–ƒ•‡–•™‡”‡‘„–ƒ‹‡†ƒ†”‡ǦƒƒŽ›œ‡†ǡƒ†–Š‡ ”‡•—Ž–•ƒ”‡†‘
—‡–‡†‹–Š‡ƒ†Ǥ
ϲ͘
ŶǀŝƌŽŶŵĞŶƚĂů
††‹–‹‘ƒŽ‡˜‹”‘‡–ƒŽ•–—†‹‡•™‡”‡”‡“—‹”‡†„›ƒŽ–”ƒ•–‘•—’’‘”––Š‡ ƒ††‹–‹‘‘ˆ–Š‡”‘—†ƒ„‘—–•‹–‘–Š‡†‡•‹‰Ǥ—Ž–‹’Ž‡†‘ —‡–•”‡“—‹”‡†ƒ††‹–‹‘ƒŽ
‹ˆ‘”ƒ–‹‘ƒ†ƒƒŽ›•‹•–‘„‡ƒ††‡†ƒ†ƒ††‹–‹‘ƒŽ”‡˜‹‡™ ›
Ž‡•ǤŠ‡ƒ††‹–‹‘ƒŽ
‡˜‹”‘‡–ƒŽ†‘
—‡–ƒ–‹‘ƒ†
‘’Ž‹ƒ
‡ƒ
–‹˜‹–‹‡•‹
Ž—†‡†ǣ
 ‡˜‹•‡†”‘Œ‡
–‡•
”‹’–‹‘
 ††‹–‹‘ƒŽ’—„Ž‹
‘—–”‡ƒ
Šƒ†˜‹”–—ƒŽ”‘‘
 ‹•—ƒŽ
’ƒ
–ƒŽ›•‹•
 ‹”—ƒŽ‹–›–—†›ƒ†
–‡”ƒ‰‡
›‘‘”†‹ƒ–‹‘
 ƒ–—”ƒŽ˜‹”‘‡––—†›

ƒœƒ”†‘—•ƒ•–‡
‹–‹ƒŽ‹–‡••‡••‡–
 ƒ–‡”—ƒŽ‹–›••‡••‡–ƒ†–‘”ƒ–‡”ƒ–ƒ‡’‘”– ‡Ž‹˜‡”ƒ„Ž‡ȋ•Ȍǣ
 ††‹–‹‘ƒŽ‡˜‹”‘‡–ƒŽƒƒŽ›•‡•ƒ††‘
—‡–ƒ–‹‘ƒ•Ž‹•–‡†ƒ„‘˜‡–‘•—’’‘”–
ƒŽ–”ƒ•ƒ’’”‘˜ƒŽǤ







 




ůĂŵĞĚĂĞŶƚƌĂůǀĞŶƵĞ^ĂĨĞƚLJ/ŵƉƌŽǀĞŵĞŶƚWƌŽũĞĐƚ͗ŵĞŶĚŵĞŶƚϯ ^ĐŽƉĞŽĨtŽƌŬ 

ϳ͘^ƵƉƉŽƌƚ^ĞƌǀŝĐĞƐ
††‹–‹‘ƒŽ‡‰‹‡‡”‹‰•–—†‹‡•Šƒ˜‡„‡‡
‘’Ž‡–‡†–‘•—’’‘”––Š‡ƒ††‹–‹‘‘ˆ–Š‡
”‘—†ƒ„‘—–•‹–‘–Š‡†‡•‹‰ƒ†–‘‡‡––Š‡
‘•–”—
–‹‘‰”ƒ–ˆ—†‹‰†‡ƒ†Ž‹‡•ǤŠ‡
ƒ††‹–‹‘ƒŽ”‡“—‹”‡†‹˜‡•–‹‰ƒ–‹‘•Šƒ˜‡‹
Ž—†‡†ǣ

–‡”•‡
–‹‘‘–”‘Ž˜ƒŽ—ƒ–‹‘•ȋ
Ȍ


‹‰Š™ƒ›ƒˆ‡–›ƒ—ƒŽȋ
ȌƒŽ›•‹•
 ‘—†ƒ„‘—–’‡”ˆ‘”ƒ
‡
Š‡
•
 ƒŽ›•‹•ƒ†‘—–”‡ƒ
Šˆ‘””‘—†ƒ„‘—–•ƒˆ‡–›ˆ‘”–Š‡˜‹•—ƒŽŽ›‹’ƒ‹”‡†
 
‹ƒŽȀŠ‡”ƒ‘—†ƒ„‘—–‘”–Š„‘—†–Š”‘—‰Š‘˜‡‡–ƒƒŽ›•‹•  ††‹–‹‘ƒŽ•—”˜‡›ȋ
ƒ•–ƒ–‹‘ƒ”
‡Žƒ–Š‡”ƒȀ
‹ƒŽȌ
 ‘‘”†‹ƒ–‹‘™‹–Šƒ–‹˜‡‡”‹
ƒ–”‹„‡•–‘‹
Ž—†‡”‡
‘‡†‡†ƒ–‹˜‡’Žƒ–
•’‡
‹‡•‹–Š‡”‘—†ƒ„‘—–Žƒ†•
ƒ’‡ƒ”‡ƒ•Ǥ
 –‹Ž‹–›
‘‘”†‹ƒ–‹‘–‘‡˜ƒŽ—ƒ–‡ƒ†”‡•‘Ž˜‡
‘ˆŽ‹
–•™‹–Š”‘—†ƒ„‘—–†‡•‹‰

‘’‘‡–••—
Šƒ•ˆ—ŽŽǦ†‡’–Š’ƒ˜‡‡–”‡
‘•–”—
–‹‘ǡ‡™•–”‡‡–Ž‹‰Š–‹‰ƒ†
†”ƒ‹ƒ‰‡•›•–‡‘†‹ˆ‹
ƒ–‹‘•Ǥ
 ”ƒ‹ƒ‰‡ƒƒŽ›•‹•ƒ••‘
‹ƒ–‡†™‹–Š”‘—†ƒ„‘—–
‘•–”—
–‹‘‹
Ž—†‹‰•‹–‹‰ƒ†
•‹œ‹‰‡™
‘˜‡›ƒ
‡•ǡ‹Ž‡–•ǡƒ†‰”‡‡‹ˆ”ƒ•–”—
–—”‡ˆƒ
‹Ž‹–‹‡•Ǥ
ϴ͘
ŶŐŝŶĞĞƌŝŶŐWůĂŶƐ͕^ƉĞĐŝĨŝĐĂƚŝŽŶƐĂŶĚ
ƐƚŝŵĂƚĞƐ
Š‡’”‘Œ‡
–†‡•‹‰Šƒ•„‡‡”‡˜‹•‡†–‘‹
‘”’‘”ƒ–‡—’–‘ˆ‘—”‡™”‘—†ƒ„‘—–•ƒ––Š”‡‡
‡š‹•–‹‰•‹‰ƒŽ‹œ‡†‹–‡”•‡
–‹‘•ƒ†‘‡•–‘’
‘–”‘ŽŽ‡†‹–‡”•‡
–‹‘Ǥ—‡–‘Ž‹‹–‡†

‘•–”—
–‹‘ˆ—†‹‰ǡ‘‡‘”‘”‡‘ˆ–Š‡”‘—†ƒ„‘—–•™‹ŽŽ„‡
‘•–”—
–‡††—”‹‰ƒˆ—–—”‡
’Šƒ•‡ƒ†–Š‡ƒ••‘
‹ƒ–‡††‡•‹‰™‹ŽŽ„‡Ž‹‹–‡†–‘–Š‡’”‡Ž‹‹ƒ”›Ž‡˜‡Žȋƒ’’”‘š‹ƒ–‡Ž›͵Ͳ ’‡”
‡–†‡•‹‰ȌǤ ‘”–Š‡ˆ—–—”‡’Šƒ•‡”‘—†ƒ„‘—–•ǡ‹–‡”‹†‡•‹‰•™‹ŽŽ„‡†‡˜‡Ž‘’‡†–‘

‘ˆ‘”–Š‡‹–‡”•‡
–‹‘•™‹–Š–Š‡‘–Š‡”’”‘’‘•‡†‹’”‘˜‡‡–•ǡ•—
Šƒ•Žƒ‡”‡†—
–‹‘•
ƒ†‡™„‹‡ˆƒ
‹Ž‹–‹‡•Ǥ‘•–‡•–‹ƒ–‹‰•—’’‘”–™‹ŽŽ„‡’”‘˜‹†‡†–‘•—’’‘”––Š‡’—”•—‹–‘ˆ ƒ††‹–‹‘ƒŽ‰”ƒ–ˆ—†‹‰ˆ‘”—ˆ—†‡†”‘—†ƒ„‘—–•Ǥ
Š‡ƒ††‹–‹‘ƒŽ”‘—†ƒ„‘—–†‡•‹‰ˆ‡ƒ–—”‡•ƒ”‡‹
Ž—†‡†‹‡ƒ
Š†‡•‹‰‹Ž‡•–‘‡ȋ͵ͷΨǡ
͸ͷΨǡͻͷΨǡͳͲͲΨƒ†–Š‡ˆ‹ƒŽ„‹††‹‰†‘
—‡–•ȌǤ
••—’–‹‘ȋ•Ȍǣ
 Š‡”‘—†ƒ„‘—–†‡•‹‰
‘’‘‡–•™‹ŽŽ”‡“—‹”‡ƒƒ††‹–‹‘ƒŽˆ‹˜‡•Š‡‡–•‘ˆ
†‡•‹‰†”ƒ™‹‰•’‡””‘—†ƒ„‘—–ˆ‘”ƒ–‘–ƒŽ‘ˆ—’–‘–™‡–›ƒ††‹–‹‘ƒŽ•Š‡‡–•Ǥ ‡Ž‹˜‡”ƒ„Ž‡ȋ•Ȍǣ







 




ĞŶƚƌĂůǀĞŶƵĞ^ĂĨĞƚLJ/ŵƉƌŽǀĞŵĞŶƚWƌŽũĞĐƚ͗W^Θ
WŚĂƐĞ ^ĐŽƉĞŽĨtŽƌŬ



 ƒ‡Ƭ•—„‹––ƒŽ•ƒ•†‡•
”‹„‡†‹–Š‡‘”‹‰‹ƒŽ•
‘’‡ǡ”‡˜‹•‡†™‹–Š”‘—†ƒ„‘—–
†‡•‹‰•Ǥ
ϵ͘ŽŶƐƚƌƵĐƚŝŽŶŝĚ^ƵƉƉŽƌƚ
‘
Šƒ‰‡•ƒ”‡‡‡†‡†ˆ‘”–Š‹•–ƒ•Ǥ
ϭϬ͘
ŶŐŝŶĞĞƌŝŶŐ^ĞƌǀŝĐĞƐƵƌŝŶŐŽŶƐƚƌƵĐƚŝŽŶ
‹–Š™‹ŽŽ’”‘˜‹†‡
‘•–”—
–‹‘‡‰‹‡‡”‹‰•—’’‘”–ˆ‘”–Š‡’”‘Œ‡
–‹
Ž—†‹‰ƒ•Ǧ
‡‡†‡†‘Ǧ•‹–‡•—’’‘”––‘–Š‡‹–›ˆ‘”
Žƒ”‹ˆ›‹‰†‡•‹‰‹••—‡•ǡ˜‡”‹ˆ›‹‰
‘’Ž‹ƒ
‡™‹–Š
–Š‡
‘–”ƒ
–†‘
—‡–•ǡƒ††”‡••‹‰”‡“—‡•–•ˆ‘”‹ˆ‘”ƒ–‹‘ȋ
•Ȍǡ”‡˜‹‡™‹‰
‘–”ƒ
–‘”
•—„‹––ƒŽ•ǡƒ†‡˜ƒŽ—ƒ–‹‰ƒ†’”‘
‡••‹‰
‘•–”—
–‹‘
Šƒ‰‡‘”†‡”•Ǥ‹–Š™‹ŽŽ
•—’’‘”––Š‡‹–›ǯ•‹†‡’‡†‡–™‹–Š‡‰‹‡‡”‹‰”‡Žƒ–‡†•‡”˜‹ ‡•–‘ˆƒ
‹Ž‹–ƒ–‡–Š‡‹”
ƒƒ‰‡‡–‘ˆ–Š‡’”‘Œ‡
–ǯ•
‘•–”—
–‹‘Ǥ
&ŝĞůĚsŝƐŝƚƐ
‹–Š™‹ŽŽ
‘†—
–‘–ŠŽ›ǡȋ—’–‘‡‹‰Š–‡‡Ȍǡ•‹–‡˜‹•‹–•–‘ƒ•™‡”†‡•‹‰”‡Žƒ–‡† “—‡•–‹‘•ƒ†•—’’‘”––Š‡‹–›ǯ•‘Ǧ•‹–‡”‡’”‡•‡–ƒ–‹˜‡‹‘„•‡”˜‹‰–Š‡‘–”ƒ –‘”ǯ•
™‘”ˆ‘”
‘ˆ‘”ƒ
‡™‹–Š–Š‡‘–”ƒ
–‘
—‡–•ǤŠ‡‹–›ǯ•™‹ŽŽŠƒ˜‡’”‹ƒ”›
”‡•’‘•‹„‹Ž‹–›‹‘„•‡”˜‹‰
‘•–”—
–‡†ˆƒ
‹Ž‹–‹‡•’”‹‘”–‘„—”‹ƒŽǡ‘„•‡”˜‹‰–‡•–•”‡“—‹”‡†
–‘„‡’‡”ˆ‘”‡†„›–Š‡‘–”ƒ
–‘”‘””‡ˆ‡”‡
‡†‹–Š‡
‘–”ƒ
–†‘
—‡–•ƒ†ƒ

‡’–‹‰
™‘”
‘’Ž‡–‡†„›–Š‡‘–”ƒ
–‘”Ǥ

‹–Š™‹ŽŽ
‘‘”†‹ƒ–‡™‹–Š‹–›ƒ†•–ƒˆˆ–‘
‘„‹‡–Š‡ˆ‹‡Ž†˜‹•‹–•™‹–Š

‘•–”—
–‹‘’”‘‰”‡••‡‡–‹‰•ƒ†‘–Š‡”
‘•–”—
–‹‘‡‡–‹‰•–‘”‡˜‹‡™–Š‡’”‘Œ‡
–
•–ƒ–—•ǡ•—„‹––ƒŽ“—‡•–‹‘•ǡ
ǯ•ǡǯ•ǡƒ†–Š‡‘–”ƒ
–‘”ǯ•
‘•–”—
–‹‘•
Š‡†—Ž‡Ǥ

ƒ
Š•‹–‡˜‹•‹–™‹ŽŽ„‡†‘
—‡–‡†™‹–Š’Š‘–‘‰”ƒ’Š•ƒ†™”‹––‡‘–‡•–‘‹ŽŽ—•–”ƒ–‡ƒ† †‡•
”‹„‡‹–‡•–Šƒ–™‡”‡‹•’‡
–‡†ƒ†Ȁ‘”†‹•
—••‡†ƒ†–‘†‘
—‡–†‡
‹•‹‘•ƒ†‡‘”
†‹”‡
–‹‘’”‘˜‹†‡†–‘–Š‡‘–”ƒ
–‘”ǤŠ‡‘•—Ž–ƒ–•ŠƒŽŽƒŽ•‘ƒ‹–ƒ‹ƒ
‘’›‘ˆ
”‡†Ž‹‡††”ƒ™‹‰ƒ”—’•–‘†‘
—‡–‘„•‡”˜‡††‡•‹‰†‡˜‹ƒ–‹‘•
 ^tWWWŵĞŶĚŵĞŶƚƐ
‹–Š™‹ŽŽ’”‘˜‹†‡ƒ—ƒŽ‹ˆ‹‡†‡˜‡Ž‘’‡”ȋȌ–‘’”‡’ƒ”‡–‘”™ƒ–‡” ‘ŽŽ—–‹‘”‡˜‡–‹‘ŽƒȋȌƒ‡†‡–•–‘†‘
—‡–‘†‹ˆ‹
ƒ–‹‘•–‘–Š‡

‘•–”—
–‹‘•‹–‡•–‘”™ƒ–‡””—‘ˆˆ
‘–”‘Ž•–Šƒ–ƒ”‡†‡–‡”‹‡†–‘„‡‡
‡••ƒ”›„›–Š‡
†‡•‹‰ƒ–‡†—ƒŽ‹ˆ‹‡†”ƒ
–‹–‹‘‡”ȋȌǡ‘”‘–Š‡”“—ƒŽ‹ˆ‹‡†‹†‹˜‹†—ƒŽǤ
ƒ‡†‡–•™‹ŽŽ„‡’”‘˜‹†‡†–‘–Š‡‘–”ƒ
–‘”ˆ‘”‹•‡”–‹‘‹–‘–Š‡‘•‹–‡ƒ†
•—„‹––‡†–‘–Š‡‹–›ˆ‘”—’Ž‘ƒ†–‘–Š‡–‘”™ƒ–‡”—Ž–‹’’Ž‹ ƒ–‹‘ƒ†‡’‘”–”ƒ
‹‰
›•–‡ȋȌǤ
–ƒ••—‡†–Šƒ––Š‡‹–›ǯ•†‡•‹‰ƒ–‡†‡‰ƒŽŽ›‡•’‘•‹„Ž‡‡”•‘ ȋȌǡ™‹ŽŽƒƒ‰‡
‘’Ž‹ƒ
‡”‡Žƒ–‡†•—„‹––ƒŽ•ˆ‘”–Š‡
‡‡”ƒŽ‘•–”—
–‹‘
‡”‹–‹
Ž—†‹‰•—„‹––‹‰–Š‡
ƒ†Ǥ







 




ůĂŵĞĚĂĞŶƚƌĂůǀĞŶƵĞ^ĂĨĞƚLJ/ŵƉƌŽǀĞŵĞŶƚWƌŽũĞĐƚ͗ŵĞŶĚŵĞŶƚϯ ^ĐŽƉĞŽĨtŽƌŬ 

ZĞƋƵĞƐƚƐĨŽƌ/ŶĨŽƌŵĂƚŝŽŶ;Z&/ƐͿ
‹–Š™‹ŽŽ’”‘˜‹†‡
Žƒ”‹ˆ‹
ƒ–‹‘ƒ†‹–‡”’”‡–ƒ–‹‘‘ˆ†”ƒ™‹‰•ƒ†•’‡
‹ˆ‹
ƒ–‹‘•ǡƒ•
”‡“—‡•–‡†„›–Š‡‹–›‘”ǡ‹”‡•’‘•‡–‘”‡“—‡•–•ˆ‘”‹ˆ‘”ƒ–‹‘ȋ •Ȍˆ”‘–Š‡
‘–”ƒ
–‘”Ǥ‹–Š™‹ŽŽ”‡˜‹‡™
•ƒ†™‘”™‹–Š–Š‡‘–”ƒ
–‘”ǡ–Š‡‹–›ƒ†‘–Š‡”•
ƒ•‡‡†‡†ǡ–‘†‡˜‡Ž‘’ƒ’’”‘’”‹ƒ–‡™”‹––‡
Žƒ”‹ˆ‹
ƒ–‹‘•Ǥ‡•‹‰
Žƒ”‹ˆ‹
ƒ–‹‘••ŠƒŽŽ„‡

‘‘”†‹ƒ–‡†™‹–Š–Š‡‹–›ǯ•‘Ǧ•‹–‡”‡’”‡•‡–ƒ–‹˜‡ƒ†‘–Š‡”•–ƒˆˆ–‘ƒ††”‡••“—‡•–‹‘• ”ƒ‹•‡†„›–Š‡‘–”ƒ
–‘”ǡ˜‡†‘”•ǡ‹–›•–ƒˆˆǡ”‡‰—Žƒ–‘”•ǡƒ†‘–Š‡”•Ǥ
••ŠƒŽŽ„‡
•—„‹––‡†–‘–Š‡™Š‘™‹ŽŽ–Š‡†‡–‡”‹‡™Š‡–Š‡”‘•—Ž–ƒ–•—’’‘”–‹•”‡“—‹”‡†–‘ †‡˜‡Ž‘’ƒ”‡•’‘•‡Ǥ
ŽŶƐƚƌƵĐƚŝŽŶŚĂŶŐĞKƌĚĞƌƐ
•”‡“—‡•–‡†„›–Š‡‹–›ǡ‹–Š™‹ŽŽƒ••‹•–‹‡˜ƒŽ—ƒ–‹‰ Šƒ‰‡†
‘†‹–‹‘•ǡ

‘•–”—
–‹‘
‘–”ƒ
–”‡“—‹”‡‡–•ǡƒ†’”‡’ƒ”‹‰†‘
—‡–ƒ–‹‘ƒ†”‡˜‹•‡††‡•‹‰
‹ˆ‘”ƒ–‹‘–‘•—’’‘”–
‘•–”—
–‹‘
Šƒ‰‡‘”†‡”•–‘„‡‹
‘”’‘”ƒ–‡†‹–‘–Š‡
‘–”ƒ
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ĞŶƚƌĂůǀĞŶƵĞ^ĂĨĞƚLJ/ŵƉƌŽǀĞŵĞŶƚWƌŽũĞĐƚ͗W^Θ
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EŽŚĂŶŐĞƚŽƚŚŝƐƚĂƐŬ
dĂƐŬ







 




ABCEFHolder Identifier :                                      
                                  Certificate No : 570096406688

CERTIFICATE OF LIABILITY INSURANCE

DATE(MM/DD/YYYY)
11/08/2022
IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must have ADDITIONAL INSURED provisions or be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s).

THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS

CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER.

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CANCELLATIONCERTIFICATE HOLDER

AUTHORIZED REPRESENTATIVE
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©1988-2015 ACORD CORPORATION. All rights reserved.

The ACORD name and logo are registered marks of ACORD

SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE

EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS.







 








AGENCY CUSTOMER ID:

ADDITIONAL REMARKS SCHEDULE
LOC #:

ADDITIONAL REMARKS

THIS ADDITIONAL REMARKS FORM IS A SCHEDULE TO ACORD FORM, FORM NUMBER: ACORD 25 FORM TITLE: Certificate of Liability Insurance EFFECTIVE DATE:

CARRIER NAIC CODE

POLICY NUMBER

NAMED INSUREDAGENCY
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ADDITIONAL POLICIES If a policy below does not include limit information, refer to the corresponding policy on the ACORD certificate form for policy limits.

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INSURER

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INSURER

INSURER(S) AFFORDING COVERAGE
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ACORD 101 (2008/01) © 2008 ACORD CORPORATION. All rights reserved.

The ACORD name and logo are registered marks of ACORD







 




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AGENCY CUSTOMER ID:

ADDITIONAL REMARKS SCHEDULE
LOC #:

ADDITIONAL REMARKS

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CARRIER NAIC CODE

POLICY NUMBER

NAMED INSUREDAGENCY
6HH&HUWLILFDWH1XPEHU

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CG 20 10 04 13 © ISO Properties, Inc., 2012 Page 1 of 2 ††

POLICY NUMBER: TB7611B8T8Z6042 COMMERCIAL GENERAL LIABILITY CG 20 10 04 13

THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY.

ADDITIONAL INSURED – OWNERS, LESSEES OR
CONTRACTORS – SCHEDULED PERSON OR

ORGANIZATION

This endorsement modifies insurance provided under the following:

COMMERCIAL GENERAL LIABILITY COVERAGE PART

A. Section II – Who Is An Insured is amended to
include as an addit ional insured the person(s) or
organization(s) s hown in the Schedule, but only
with respect to liability for "bodily injury", "property damage" or "personal an d advertis ing inj ury"
caused, in whole or in part, by:
1 . Your acts or omissions; or

2. The acts or omissions of those acting on your
behalf;
in the performance of your ongoing operations for
the additional insur ed(s) at t he location(s)
designated above.

However:
1 . The insurance afforded to such additional
insured only applies to the extent permitted by
law; and
2 . If coverage provided to the additional insured is
required by a contract or agreement, the
insurance afforded to such additional insured
will not be broader than that which you are
required by the contract or agreement to provide
for such additional insured.

B. With respect to the insurance afforded to these
additional insureds, the following additional
exclusions apply:

This insurance does not apply to "b odily injury" or
"property damage" occurring after:

1 . All work, including materials, parts or equipment
furnished in connection with such work, on the
project (other than service, maintenance or
repairs) to be performed by or on behalf of the
additional insure d(s) at the location of the
covered operations has been completed; or
2 . That portion of "your work" out o f which the
injury or damage arises has been put to its
intended use by any person or organization
other than another contractor or subcontractor
engaged in performing operations for a principal
as a part of the same project.

C. With respect to the insurance afforded to these
additional insureds, the following is added to
Section III – Limits Of Insurance:

If coverage provided to the additional insured is
required by a contract or agreement, the most we
will pay on behalf of the additional insured is the
amount of insurance:
1 . Required by the contract or agreement; or
2 . Available under the applicable Limits of
Insurance shown in the Declarations;
whichever is less.

This endorsement shall not increase the applicable
Limits of Insurance shown in the Declarations.








 




CG 20 10 04 13 © Insurance Services Office, Inc., 2012 Page 2 of 2

SCHEDULE

Name Of Additional Insured Person(s)
Or Organization(s) Location(s) Of Covered Operations
Any Person or Organization to whom you become
obligated to include as an Additional Insured as a result of any contract or agreement you enter into.

Per the contract or agreement

Information required to complete this Schedule, if not shown above, will be shown in the Declarations.








 




LC 24 20 11 18 © 2018 Liberty Mutual Insurance Page 1 of 1 Includes copyrighted material of Insurance Services Office, Inc., with its permission.

Policy Number TB7-611-B8T8Z6-042
Issued by Liberty Insurance Corp.

THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY.

OTHER INSURANCE AMENDMENT – SCHEDULED ADDITIONAL INSURED

This endorsement modifies insurance provided under the following:

COMMERCIAL GENERAL LIABILITY COVERAGE PART

PRODUCTS/COMPLETED OPERATIONS LIABILITY COVERAGE PART

LIQUOR LIABILITY COVERAGE PART

If you are obligated under a written agreement to provide liability insurance on a primary, excess, contingent, or any other basis for any person(s) or organization(s) shown in the S chedule of this endorsement that qualifies as an additional insured on this Policy, this Policy will apply solely on the basis required by such written agreement and Paragraph 4. Other Insurance of Section IV – Conditions will not apply. Where the applicable written agreement does not specify on what basis the liability insurance will apply, the provisions of Paragraph 4. Other Insurance of Section IV – Conditions will apply. However, this insurance is excess over any other i nsurance available to the additional insured for which it is also covered as an additional insured for the same "occurrence", claim or "suit".

Schedule

Name of Person(s) or Organization(s):

Any person(s) or organization(s) to whom you are obligated by a written agreement to procure Additional Insured coverage under your policy.








 




CG 24 04 05 09 © Insurance Services Office, Inc., 2008 Page 1 of 1 ††

POLICY NUMBER: TB7611B8T8Z6042 COMMERCIAL GENERAL LIABILITY CG 24 04 05 09

WAIVER OF TRANSFER OF RIGHTS OF RECOVERY

AGAINST OTHERS TO US

This endorsement modifies insurance provided under the following:

COMMERCIAL GENERAL LIABILITY COVERAGE PART

PRODUCTS/COMPLETED OPERATIONS LIABILITY COVERAGE PART

SCHEDULE

Name Of Person Or Organization:

PURSUANT TO APPLICABLE WRITTEN CONTRACT OR AGREEMENT YOU ENTER INTO

Information required to complete this Schedule, if not shown above, will be shown in the Declarations.

The following is added to Paragraph 8. Transfer Of
Rights Of Recovery Against Others To Us of Sec-
tion IV – Conditions:

We waive any right of recovery we may have against
the person or organization shown in the Schedule
above because of payments we make for injury or
damage arising out of your ongoing operations or
"your work" done under a contract with that person or
organization and included in the "products-completed
operations hazard". This waiver applies only to the
person or organization shown in the Schedule above.







 




CA 20 48 10 13 © Insurance Services Office, Inc., 2011 Page 1 of 1

POLICY NUMBER: AS2-611-B8T8Z6-062 COMMERCIAL AUTO
CA 20 48 10 13

THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY.

DESIGNATED INSURED FOR

COVERED AUTOS LIABILITY COVERAGE

This endorsement modifies insurance provided under the following:

AUTO DEALERS COVERAGE FORM

BUSINESS AUTO COVERAGE FORM

MOTOR CARRIER COVERAGE FORM

With respect to coverage provided by this endorsement, the provisions of the Coverage Form apply unless modified by this endorsement.

This endorsement identifies person(s) or organization(s) who are "insureds" for Covered Autos Liability Coverage under the Who Is An Insured provision of the Coverage Form. This endorsement does not alter coverage provided in the Coverage Form.

SCHEDULE

Name Of Person(s) Or Organization(s):

Blanket - Any person or organization whom you have agreed in writing to add as an Additional Insured but only to coverage and minimum limits of insurance required by the written agreement,and in no event to exceed either the scope of coverage or the limits of insurance provided in this policy.

Information required to complete this Schedule, if not shown above, will be shown in the Declarations.

Each person or organization shown in the Schedule is
an "insured" for Covered Autos Liability Coverage, but
only to the extent that person or organization qualifies as an "insured" under the Who Is An Insured provision
contained in Paragraph A . 1 . of Section II – Covered Autos Liability Coverage in the Business Auto and
Motor Carrier Coverage Forms and Paragraph D.2. of
Section I – Covered Autos Coverages of the Auto
Dealers Coverage Form.







 




CA 04 44 10 13 © Insurance Services Office, Inc., 2011 Page 1 of 1

POLICY NUMBER: AS2-611-B8T8Z6-062 COMMERCIAL AUTO
CA 04 44 10 13

THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY.

WAIVER OF TRANSFER OF RIGHTS OF RECOVERY

AGAINST OTHERS TO US (WAIVER OF SUBROGATION)

This endorsement modifies insurance provided under the following:

AUTO DEALERS COVERAGE FORM

BUSINESS AUTO COVERAGE FORM

MOTOR CARRIER COVERAGE FORM

With respect to coverage provided by this endorsement, the provisions of the Coverage Form apply unless modified by the endorsement.

SCHEDULE

Name(s) Of Person(s) Or Organization(s):

Any person or organization for whom you perform work under a written contract if the contract requires you to obtain this agreement from us,but only if the contract is executed prior to the injury or damagae occuring.

Information required to complete this Schedule, if not shown above, will be shown in the Declarations.

The Transfer Of Rights Of Recovery Against Others
To Us condition does not apply t o the person(s) or
organization(s) shown in the Schedule, but only to the
extent that subrogation is waived prior to the "accident" or the "loss" under a contract with that person or
organization.







 




75 State Street, Suite 701
Boston, Massachusetts 02109
tel: 617 452-6000
COA-HURRELL, WILLIAM-Clement Ave-Alameda, CA-052522

CERTIFICATE
I, Paul T. Milligan, Secretary/Clerk of CDM Smith Inc., a Massa chusetts corporation, do hereby certify that William E. Hurrell holds the position of Vice Pres ident, which entitles Mr. Hurrell to execute and deliver proposals, contracts and agreements for the performance of professional services in the name and on behalf of CDM Smith Inc. Further, Mr. Hurrell has been d elegated the authority to execute and deliver proposals, contracts and agreements for the performance of professional services specifically for the project titled Clement Avenue Safety Improvement Project in the City of Alameda, California up to $1,360,633.

I further certify that the foregoing is consistent with the Co ntract Signing Authority Policy and with the By-laws of the said corporation.

IN WITNESS WHEREOF, I have executed this certificate and have caused the corporate seal of CDM Smith Inc. to be hereunder affixed on this 25
th day of May 2022.

__________________________________________
Paul T. Milligan- Secretary/Clerk of the Corporatio n

_________________
___________________________________________________
_
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